NURSING CARE PLAN
ASSESSMENTNEEDNURSING DIAGNOSISPLAN OFCARENURSING INTERVENTIONEVALUATION
JA NUAR Y24-26,2008
-with O2inhalation vianasalcannula-cracklingsoundhearduponlung aus-cultation-intermittent coughnoted-unpro-ductivecough-weak -RR-24bpmPHYSIOLOGY/OXYGE NATIONIneffective airwayclearance related toretained secretionssecondary to PTB.
PTB is a chronic,recurrent, infection caused by some bacteria. Thecommon TB popular inthe Philippines & other Asian countries isPulmonary (lung), due toM. Tuberculosis. A personwho acquired this kind of bacteria from a person bysneezing, coughing,talking, will enter to thelungs and may grow to produce secretions. Thesesecretions may lodge toairways if not coughed up.There will be anineffective airwayclearance.
http://www.sebudoctorsuniversity.edu/hospital/cardio/chua183.htmlWithin 8 hoursspan of nursingcare will be ableto:a.)expectoratesecretions b.)demonstrateinterventionsuch as deep breathing1.Auscultated breathsounds & assessed air movement
to ascertainstatus & note progress.
2.Elevated head of the bed/change positionevery 2 hours & prn
totake advantage of gravity decreasingpressure on thediaphragm &enhancing drainage of ventilation to diff. lungsegments.
3.Encouraged deep breathing & coughingexercise
®promotes optimal chestexpansion & drainage of secretions.
4.Encouraged increasefluid intake
®to help liquefy secretions
5.Encouraged/providedwarm versus cold liquidsas appropriate.6.Provided supplementalhumidification, if needed(nebulizer, O2inhalation)7.Provided back tappingafter nebulization
tomove the secretions inthe lungs